Very low risk ST-segment elevation myocardial infarction? It exists and may be easily identified

Early discharge protocols have been proposed for ST-segment elevation myocardial infarction (STEMI) low risk patients despite the existence of few but significant cardiovascular events during mid-term follow-up. We aimed to identify a subgroup of patients among those considered low-risk in which prognosis would be particularly good. We analyzed 30-day outcomes and long-term follow-up among 1.111 STEMI patients treated with reperfusion therapy. Multivariate analysis identified seven variables as predictors of 30-day outcomes: Femoral approach; age > 65; systolic dysfunction; postprocedural TIMI flow < 3; elevated creatinine level > 1.5 mg/dL; stenosis of left-main coronary artery; and two or higher Killip class (FASTEST). A total of 228 patients (20.5%), defined as very low-risk (VLR), had none of these variables on admission. VLR group of patients compared to non-VLR patients had lower in-hospital (0% vs. 5.9%; p < 0.001) and 30-day mortality (0% vs. 6.25%: p < 0.001). They also presented fewer in-hospital complications (6.6% vs. 39.7%; p < 0.001) and 30-day major adverse events (0.9% vs. 4.5%; p = 0.01). Significant mortality differences during a mean follow-up of 23.8 ± 19.4 months were also observed (2.2% vs. 15.2%; p < 0.001). The first VLR subject died 11 months after hospital discharge. No cardiovascular deaths were identified in this subgroup of patients during follow-up. About a fifth of STEMI patients have VLR and can be easily identified. They have an excellent prognosis suggesting that 24–48 h in-hospital stay could be a feasible alternative in these patients.

Choking RECtified: embodied expertise beyond Dreyfus

On a Dreyfusian account performers choke when they reflect upon and interfere with established routines of purely embodied expertise. This basic explanation of choking remains popular even today and apparently enjoys empirical support. Its driving insight can be understood through the lens of diverse philosophical visions of the embodied basis of expertise. These range from accounts of embodied cognition that are ultra conservative with respect to representational theories of cognition to those that are more radically embodied. This paper provides an account of the acquisition of embodied expertise, and explanation of the choking effect, from the most radically enactive, embodied perspective, spelling out some of its practical implications and addressing some possible philosophical challenges. Specifically, we propose: (i) an explanation of how skills can be acquired on the basis of ecological dynamics; and (ii) a non-linear pedagogy that takes into account how contentful representations might scaffold skill acquisition from a radically enactive perspective.